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Background: There is a lack of systematic information documenting recognition of potentially life-threatening complications and decisions to seek care, as well as reaching care and the specific steps in that process. In response to this gap in knowledge, a multi-country mixed methods study was conducted to illuminate the dynamics driving Delays 1 and 2 across seven countries for maternal and newborn illness and death., Methods: A common protocol and tools were developed, adapted by each of seven study teams depending on their local context (Ethiopia, India, Indonesia, Nigeria, Tanzania, Uganda, and Nepal). Maternal and newborn illness, and maternal and newborn death cases were included. Trained interviewers conducted event narratives to elicit and document a detailed sequence of actions, from onset of symptoms to the resolution of the problem. Event timelines were constructed, and in-depth interviews with key informants in the community were conducted. Transcripts were coded and analyzed for common themes corresponding to the three main domains of recognition, decision-making, and care-seeking., Results: Maternal symptom recognition and decision-making to seek care is faster than for newborns. Perceived cause of the illness (supernatural vs. biological) influences the type of care sought (spiritual/traditional vs. formal sector, skilled). Mothers, fathers, and other relatives tend to be the decision-makers for newborns while husbands and elder females make decisions for maternal cases. Cultural norms such as confinement periods and perceptions of newborn vulnerability result in care being brought in to the home. Perceived and actual poor quality of care was repeatedly experienced by families seeking care., Conclusion: The findings link to three action points: (1) messaging around newborn illness needs to reinforce a sense of urgency and the need for skilled care regardless of perceived cause; (2) targeted awareness building around specific maternal danger signs that are not currently recognized and where quality care is available is needed; and (3) designing appropriate contextualized messages. This research links to and supports a number of current global initiatives such as Ending Preventable Maternal Mortality, the Every Newborn Action Plan, the WHO Quality of Care framework, and the WHO guidelines on simplified management of newborn sepsis at the community level. This type of research is invaluable for designing programs to improve maternal and newborn survival to achieve ambitious global targets.

Background: Although maternal and newborn mortality have decreased 44 and 46% respectively between 1990 and 2015, achievement of ambitious Sustainable Development Goal targets requires accelerated progress. Mortality reduction requires a renewed focus on the continuum of maternal and newborn care from the household to the health facility. Although barriers to accessing skilled care are documented for specific contexts, there is a lack of systematic evidence on how women and families identify maternal and newborn illness and make decisions and subsequent care-seeking patterns. The focus of this multi-country study was to identify and describe illness recognition, decision-making, and care-seeking patterns across various contexts among women and newborns who survived and died to ultimately inform programmatic priorities moving forward., Methods: This study was conducted in seven countries-Ethiopia, Tanzania, Uganda, Nigeria, India, Indonesia, and Nepal. Mixed-methods were utilized including event narratives (group interviews), in-depth interviews (IDIs), focus group discussions (FDGs), rapid facility assessments, and secondary analyses of existing program data. A common protocol and tools were developed in collaboration with study teams and adapted for each site, as needed. Sample size was a minimum of five cases of each type (e.g., perceived postpartum hemorrhage, maternal death, newborn illness, and newborn death) for each study site, with a total of 84 perceived PPH, 45 maternal deaths, 83 newborn illness, 55 newborn deaths, 64 IDIs/FGDs, and 99 health facility assessments across all sites. Analysis included coding within and across cases, identifying broad themes on recognition of illness, decision-making, and patterns of care seeking, and corresponding contextual factors. Technical support was provided throughout the process for capacity building, quality assurance, and consistency across sites., Conclusion: This study provides rigorous evidence on how women and families recognize and respond to maternal and newborn illness. By using a common methodology and tools, findings not only were site-specific but also allow for comparison across contexts.